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126126 THE EWHA MEDICAL JOURNALTHE EWHA MEDICAL JOURNAL
Ectopic Pregnancy Implanted on Uterine Myoma
Min Kyoung Kim, Hyun Soo Park, Myung Hwa Lee, Sung Hee Kim, Jung Hwan ShinDepartment of Obstetrics and Gynecology, Eulji General Hospital, University of Eulji College of Medicine, Seoul, Korea
Introduction
Ectopic pregnancy is a very common diagnosis (2% of preg-
nancies) and implantation location varies. About 97% of ectopic
pregnancies are implanted within the fallopian tube, and ectopic
implantation can occur in other pelvic and abdominal locations
[1]. Although very rarely reported, non-tubal ectopic pregnan-
cies might lead to significant diagnostic challenge and morbid-
ity. We report the first case of subserosal myoma ectopic preg-
nancy, confirmed by laparoscopy and biopsy result.
Case
The patient was a 34-year-old, gravida 2 para 1 woman. Her
last childbirth was 4 years ago. At admission, the patient was
complaining moderate lower abdominal pain. Her last menstrual
period was 7 weeks ago and urinary pregnancy test was positive.
Her initial blood pressure was 110/80 mmHg, pulse was 72 beats
per minute and she was afebrile. The patient’s abdomen was soft
with lower abdominal tenderness. Trans-vaginal sonography re-
vealed an empty uterine endometrium with 2.35×2.28 cm sized
hypoechoic cystic shadow adjacent to the right adnexa (Fig. 1).
The anterior cul-de-sac fluid collection was 4.03 cm suggesting
Case Report
Ewha Med J 2015;38(3):126-128http://dx.doi.org/10.12771/emj.2015.38.3.126pISSN 2234-3180 • eISSN 2234-2591
Ectopic pregnancy is an implantation of the fertilized ovum outside the uterine cavity. Most of ectopic pregnancies are located within the fallopian tube. We describe a rare case of 34-year-old woman complaining of lower abdominal pain and positive uri-nary pregnancy test. Pelvic ultrasound exam suggested tubal pregnancy with hemo-peritoneum. However, pelviscopy revealed the bleeding point was subserosal myoma located just next to the right ovary. Uterus and both fallopian tubes were grossly free. Laparoscopic myomectomy with ectopic mass excision was performed and we ob-served the serial decrease of β-hCG level. Patient was well recovered and postopera-tive finding was not remarkable. Hereby, we report a rare case of ectopic pregnancy on uterine myoma with subserosal type with a brief review of literatures. (Ewha Med J 2015;38(3):126-128)
Received April 13, 2015 Accepted July 2, 2015
Corresponding authorJung Hwan ShinDepartment of Obstetrics and Gynecology, Eulji General Hospital, University of Eulji College of Medicine, 68 Hangeulbiseong-ro, Nowon-gu, Seoul 01830, KoreaTel: 82-2-970-8245, Fax: 82-2-970-8429E-mail: sjh3102@eulji.ac.kr
Key WordsEctopic pregnancy; Myoma; Ovarian neoplasm; Myomectomy; Laparoscopy
Fig. 1. Vaginal sonography. It reveals empty endometrium in uterus with 1.05 cm sized G-sac like shadow around the right ovary is ob-served.
127THE EWHA MEDICAL JOURNAL
Ectopic Pregnancy on Subserosal Myoma
hemoperitoneum. Measure of β-hCG was 11,941.1 at presenta-
tion.
Initial vital sign was stable, but the patient complained of ag-
gravating pain with notable abdominal distension. Emergency
laparoscopy was arranged directly. On operation field, about
500 mL blood collection was seen in pelvic cavity. A bleeding
point was noted on the subserosal uterine myoma (2×2 cm)
between the right upper body of uterus and right ovary (Fig. 2).
The whole mass including myoma was ligated with an endo-
loop and cut with laparoscopic scissors. The specimen was put
in endo-pouch and taken out completely. Dilatation and curet-
tage was done for assuring ectopic pregnancy. Pathologic find-
ings confirmed ectopic pregnancy on uterine myoma; several
fragments of myomatous nodule, aggregating about 3.0×2.2×
1.8 cm and a separate villous like tissue with blood clot, aggre-
gating about 2.5 mL blocked in myomatous nodule and villous
like tissue. Tissues from endometrial curettage showed late se-
cretory phase with predecidual change. The patient was followed
up with serial β-hCG measures and trans-vaginal ultrasonog-
raphy. The level of β-hCG was 2,128.4 IU/mL on the second
day and 54.5 IU/mL on the 12th day after the operation.
Discussion
Ectopic pregnancy constitutes 2% of total pregnancy. They
are commonly seen in women with history of tubal ligation or
pelvic inflammatory disease (PID) and in women with intra
uterine device (IUD) for contraception. Ectopic pregnancy is
also common in women on medication for infertility. Stud-
ies have shown that ovulation induction drug, especially with
clomiphene citrate, was an independent risk factor of ectopic
pregnancy. Techniques applied in the fallopian tubes, such as
zygote and gamete intrafallopian transfer (ZIFT and GIFT), also
increased the rate of ectopic pregnancies [2].
Ectopic pregnancy is responsible for the main cause of ma-
ternal mortality. We should consider ectopic pregnancy in all
women with positive pregnancy test accompanied by abdominal
pain or vaginal bleeding. Also, we have to take into account of
the possibility of ectopic pregnancy in all case of no intrauterine
gestational sac in ultrasonography despite the level of β-hCG is
already above the discriminatory zone. We cannot be too careful
doubting ectopic pregnancy.
Ninety-seven percent of ectopic pregnancies are located in
fallopian tube. Therefore, we may find out ectopic product with
ultrasound evaluation of adnexa. But, 2% are ovarian, and the
remainder are cervical or abdominal. Also, there are increasing
numbers of pregnancies reported within the scar left by caesar-
ean sections [3]. As we experienced, uterine myoma can’t be
an exception of ectopic implantation site.
A mechanism that probably can explain ectopic pregnancy on
uterine myoma of subserosal type is an invasion of the aborted
G-sac expelled out from the tubal pregnancy. Another possible
mechanism could be a secondary implantation of the abdominal
ectopic pregnancy to the pedunculated subserosal myoma. In
A B
Fig. 2. Laparoscopic findings. It shows ectopic pregnancy on subserosal uterine myoma (A), normal ovary and tube (B) (black arrow, myoma; white arrow, ruptured G-sac; shot white arrow, ovary).
128 THE EWHA MEDICAL JOURNAL
Kim MK, et al
these possible mechanisms, the first step will be a formation of
new microscopic tract of myometrium to the subserosal myoma
after trauma from previous uterine surgeries such as curettage,
cesarean delivery, myomectomy and hysteroscopy [4-6]. Then
aborted ectopic G-sac implantation may occur in uterine my-
oma. In this case, primary ectopic pregnancy site might be the
salpinx seeing that final ruptured point is the subserosal myoma
adjacent to the fallopian tube. Although abdominal ectopic
pregnancy could happen anywhere in abdominal cavity, uterine
myoma is usually consisted with smooth muscle cells with a few
superficial vessel distributed on its capsule is not so hard to im-
plant on.
Because of the rarity of subserosal myoma as an implantation
site of ectopic pregnancy, it is not easy to suspect on pelvic so-
nography at first. In addition to that, subserosal myoma extended
laterally from the uterus and may be confused with adnexal or
fallopian masses [7]. Mapping of the vascular supply to these
myoma can help to distinguish them from adnexal or retroperi-
toneal tumors including ectopic pregnancies [8,9].
There are no universal treatment guidelines nor preferred
treatment consensus for ectopic pregnancy implanted on the
subserosal myoma. However, like in tubal pregnancy, if rup-
tured, surgical treatment is the treatment of choice. The differ-
ent thing is in this case, salpinx can be preserved safely because
myomectomy is enough to control the bleeding source. Because
ectopic pregnancy on subserosal myoma is uncommon entity,
a high index of suspicion and the use of trans-vaginal Doppler
sonography can help early diagnosis. Because, doppler gives
information about the location and degree of blood flow in and
around pelvic lesions without the need to inject contrast. So,
doppler ultrasound imaging can evaluate the mapping and den-
sity of blood flow and even provide a quantitative measure of
the amount of blood flow in the implantation site [10,11]. We
should keep in mind that patient’s subserosal myoma could be a
site of ectopic pregnancy.
References
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3. Condous G, Okaro E, Alkatib M, Khalid A, Rao S, Bourne T. OC198: should an ectopic pregnancy always be diagnosed using transvaginal ultrasonography in the first trimester prior to sur-gery? Ultrasound Obstet Gynecol 2003;22(S1):53.
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5. Mcgowan L. Intramural pregnancy. JAMA 1965;192:637-638.6. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for
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7. Katz VL. Comprehensive gynecology. 5th ed. Philadelphia: Mosby Elsevier; 2007.
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9. Ueda H, Togashi K, Konishi I, Kataoka ML, Koyama T, Fujiwara T, et al. Unusual appearances of uterine leiomyomas: MR imag-ing findings and their histopathologic backgrounds. Radiograph-ics 1999;19 Spec No:S131-S145.
10. Taskin S, Taskin EA, Cengiz B. Cervical intramural ectopic preg-nancy. Fertil Steril 2009;92:395.e5-395e7.
11. Benacerraf BR, Abuhamad AZ, Bromley B, Goldstein SR, Gro-szmann Y, Shipp TD, et al. Consider ultrasound first for imaging the female pelvis. Am J Obstet Gynecol 2015;212:450-455.
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